One future for education: health care nation

Skåne University HospitalIn 2014 I offered one scenario for education’s future that seems to have a good shot at realization.  I called it “Health Care Nation,” and it presumes that the medical sector becomes the largest part of the American economy.

I included it among a brace of scenarios for the EDUCAUSE Review, and also blogged a preview here.

Let me expand upon the now, as a preview of my upcoming book.  After it I’ll check to see how this 2014 vision of the future holds up.


In this future, health care is now the largest sector of the American economy.  It employs more people and generates a bigger slice of GDP than any other service or industry, and is still growing.  Medical services plays a larger and larger role in people’s lives.  Social spaces have changed as a result, with towns and cities hosting more clinics, hospitals, drugstores, medical supply stores, and labs than in the past.  The largest medical buildings stand out in urban areas the way churches used to mark towns.

How could this come to pass?  Remember, first, what a wide range of services and domains health care encompasses in 2018.  Professional staff include nurses, surgeons, hospital administrators,  radiologists, anesthesiologists, ethicists, physicians’ assistants, pharmacists, home health care aids, lab techs, first responders, and researchers, not to mention the lawyers, IT staff, custodians, office managers, librarians, security officers, laundry workers, housekeepers, and more who keep the system running.  (For a big list, consult this OSHA page) That’s already 18 million workers in 2018, or around 14% of the labor force, according to the CDC and BLS.

It costs a lot of money to keep that system running. In 2010 the total cost was $2.6 trillion (source).  In 2011 “the United States spent $2.7 trillion on health care, more than double what was spent in 2000.”  By 2016 that became $3.4 trillion, by one account, or 17.8% of the economy that year, by another. By 2017 the medical sector cost “nearly $3.5 trillion,” according to the U.S. Centers for Medicare and Medicaid Services.

Those costs are rising – a rate of 5.3% for next year, above last year’s 4.6%, and also beyond a general inflation rate of 2.1%, according to the CMS.  That CMS center foresees continued growth coming up:

CMS projected that healthcare spending will on average rise 5.5 percent annually from 2017 to 2026 and will comprise 19.7 percent of the U.S. economy in 2026, up from 17.9 percent in 2016. By 2026, health spending is projected to reach $5.7 trillion.

(One key driver:

Prescription drugs are expected to see the fastest annual growth over the next decade, rising an average of 6.3 percent per year, due to higher drug prices and more use of specialty drugs such as those for genetic disorders and cancer.)

Melissa D. Aldridge and Amy S. Kelley go further, citing research forecasting “that, by 2040, 1 of every 3 dollars spent in the United States will be spent on health care.”

Let’s assume that last figure and call it one third of GDP devoted to the medical sector.  On the labor side, let me try some rough back of the envelope math. Say 38o million people in 2040.  If there’s 59.7% of population employed now, and we assume that rate in 2040, that yields around 227 million total workers.  With today’s rate of 14% of the total workforce employed in health care, that’s around 31,800,000 people working in that sector.  If we increase that proportion to 20% based on the sector’s rapid growth we get 45 million health care workers.  That’s an awful lot of people.

I don’t want to go into the quality of care questions with this post, or even to compare American health care financing with that of other nations (we look awful in the latter).  Here I just want to focus on quantity, establishing that in the present we have a healthy amount of evidence suggesting health care is a large industry and will continue to grow in the short and medium term future.

If health care is economically vast and we already employ an awful lot of people in health care, that scale could easily expand because of demographics.  That is, as people age, they tend to consume more health care, statistically (for example).  My readers know that the United States population is aging, as is just about every other developed nation, so we should expects costs (spending) to rise even further.  Back to CMS:

Higher spending in Medicare and Medicaid, the government health insurance program for the poor and disabled, are also expected to contribute significantly to rising health spending as the population ages and relies more heavily on healthcare services.

That aging population has also summoned up the invention of new treatments and the expansion of formerly rare ones.  Recall the steady pace of medical invention, from drugs to implants.  Think about the growth in memory care facilities, for example, or the boom in assisted living.  Atul Gawande points out that gerontology as a specialty is dangerously understaffed nationwide, despite the growing need.   Economically, all of these responses to our nation’s demographics mean escalating cost.

Let’s assume health care innovation proceeds at recent history’s pace.  We should therefore expect new treatments and technologies.  Imagine drones delivering drugs to people at home or work, not to mention bringing supplies to emergency situations.  More AI will be deployed across the health universe, from diagnosis (both professional and self-conducted) to medical research.  Telemedicine increases and robotics grows.

Rising demand for medical services won’t be met by cost savings through scale or automation, as health care is a primary victim of Baumol’s cost disease – these are services you don’t want sped up.  Every broken leg or CT scan takes time, costing hours and money.  Moreover, America’s unusual financial structure, a mix of state and federal governmental financing with large insurance companies plus the uninsured using emergency rooms for desperate care, does not suggest a reduction of complexity (and therefore costs) any time soon.  The Affordable Care Act helped keep costs from accelerating even more rapidly, but accelerate they are, even at a less drastic pace.

What does this state of affairs mean for education?

College campuses in Health Care Nation offer many academic programs devoted to medicine. Degrees in fields like nursing, surgery, radiology, gerontology, and hospital administration have expanded or been introduced to new institutions. Formerly undergraduate-only campuses now add degrees in nursing and physicians’ assistants on top of various bachelors in premed.  New topical courses have proliferated across the curriculum, from medical ethics to health care history, computer science for medicine and 3d bioinformatics modeling, the sociology of old age and the literature of long-term care, as more departments reach out to this growing need.

The number and size of attached and standalone medical schools has grown, as have relationships between campuses and the health care sector.  Some colleges and universities partner with local clinics and hospitals to share space (think professional development seminars during summer) and set up internships.  Academic libraries reach out to clinics in a strategy of information entrepreneurship.  Instructors bring in medical practitioners as classroom speakers.  Student- and faculty-driven startups seek to meet health care needs.

Different educational sectors respond to this health care driven world depending on their historical roles.  Research-I universities continue to conduct experiments and cutting-edge research.  Some if not many also operate medical facilities – clinics, hospitals, labs.  Community colleges train students for  a variety of health sector positions, including offering degrees (for example) upon which students can add further health care learning.  Many liberal arts colleges offer interdisciplinary programs in and around the medical world, bringing to bear diverse intellectual approaches while sometimes avoiding the appearance of preprofessional degrees.  State universities try to embrace all of these purposes to different degrees, depending on their individual mission.

Some multi-institutional or system-based programs enable learners to build degrees composed of classes from across a region (for example) or nation.  Registrars spend an increasing amount of time dealing with transferring medical class credits.

Many more people are involved in medical academia than ever before.  Obviously more students take more medically-related classes than ever. It seems likely that most of those students will be women, given the historical prevalence of female students in many health care and life science fields, along with the plurality of women in the student body overall.  This could contribute to an overall gendering of higher education as female, which challenges the many levels of institutionalized and personal sexism.  The Trump era suggests we should expect multiple forms of backlash.

Other academic sectors are impacted.  Development offices devote more of their resources to reaching out to the health care sector, both as more of their graduates work in that field and because of the riches found there.  Campus computing serves a larger and more challenging medical IT space.  Think of the many physical devices that must be supported, in addition to software (a vast, troubled, and growing field) and innovations of all sorts.  Recall that health care instructions is often in the lead for using technology, which means campus IT will have to help support the use of VR and MR for visualization, robotics and software for simulation, and the combination of big data, data analytics, and AI.  A growing percentage of IT resources flow to health care needs; perhaps friction will arise between those fields and the rest.

I imagine that a growing proportion of students studying in the full range of medical fields will be adult learners.  That’s partly because “nontraditional” learners already occupy a big chunk of the higher ed student body, a number likely to grow as America ages.  It’s also because professionals will seek reskilling at their fields evolve.  A growing proportion of traditional age (18-22) students should take medical programs, given the job opportunities.  Behind them we can envision secondary school students participating in more pre-pre-med classes than there are in 2018.  Indeed, we can expect high schools to offer more and new classes in such fields.  Perhaps some teens will hold well known medical figures to be aspirational heroes.  A growing number of them may already be familiar with eldercare practices, given demographics and housing trends.

How does this 2014 vision appear in 2018?

Overall, this seems to be on schedule.  Despite the Affordable Care Act, medical costs just keep rising, as does the sector’s entire size.  The Trump administration and GOP control of Congress means we won’t see anything like national health care anytime soon; I didn’t expect Trump in 2014, but neither did I anticipate Medicare for All, which isn’t in the cards now.  The demographics I mentioned in 2014 continue in 2018.

Speaking of not expecting Trump, I also didn’t expect an anti-immigration wave.  Typically immigrants trend young, so without those infusions America is likely to age more rapidly… meaning my scenario is even more likely to occur.

The educational impact is certainly there.  Everywhere I look there are more medical classes, majors, faculty, students, and schools.   Every time I present this scenario academic audiences consider it very likely, especially if they are based in regions where aging is most rapidly occurring (the American midwest and northeast).

One bit hasn’t come to pass yet: younger folk seeing medical people as aspirational heroes.  I haven’t spotted Craig Venter t-shirts in the wild.  There have been campaigns to increase public support for medical staff.  I could well have missed popular culture instances of medical heroes; please let me know if you’ve spotted one.

If this scenario occurs, at some point the effects will wear off once the growth curve flattens.  It might take an Ocasio-Cortez administration successfully implementing national health care, or a set of medical practices that actually reduces costs, or a small cultural revolution in favor of preventive medicine that reduces our demand on high-impact health services, or an economic disaster that saps demand, but we should expect an end point to this curve.  Educators should consider this as an end point to their health expansion strategy.

(Skåne University Hospital by Maria Eklind; money and pills photo by images_of_money; health care for all bodies by Quinn Dombrowski; medical school by Bert Knottenbeld; medical mannequins by Ted Eytan)

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